Differential Diagnosis for 39-year-old Female with Scapular Pain
- Single most likely diagnosis:
- Musculoskeletal strain: The patient's symptoms of pain below the left scapula, worsening with bending and lifting, and improvement with Flexeril (a muscle relaxant) and arm extension suggest a musculoskeletal origin. Overuse of the left arm due to right arm issues and caring for a new foster dog further supports this diagnosis.
- Other Likely diagnoses:
- Thoracic outlet syndrome: Pain radiating from the back into the chest with deep breaths and arm movements could indicate thoracic outlet syndrome, where the nerves and/or blood vessels between the neck and shoulder are compressed.
- Costochondritis: Inflammation of the cartilage that connects the ribs to the breastbone could cause pain that worsens with deep breathing and movement, although it typically presents with more localized chest wall pain.
- Myofascial pain syndrome: Given the patient's improvement with Flexeril and the nature of her pain, myofascial pain syndrome, which involves pain and inflammation of the fascia (the connective tissue surrounding muscles), is a possible diagnosis.
- Do Not Miss diagnoses:
- Pulmonary embolism: Although the patient denies chest pain at rest, diaphoresis, or nausea, pulmonary embolism can sometimes present atypically, especially if the embolism is small or peripheral. The radiation of pain into the chest with deep breaths warrants consideration of this potentially life-threatening condition.
- Pneumothorax: Sudden onset of scapular pain that worsens with deep breathing could indicate a pneumothorax, especially if there was any trauma or underlying lung disease.
- Myocardial infarction: While less likely given the patient's age and lack of typical cardiac symptoms, atypical presentations of myocardial infarction can occur, and it is crucial to consider this diagnosis, especially with any chest pain or discomfort.
- Rare diagnoses:
- Pancoast tumor: A rare type of lung cancer that can cause shoulder and scapular pain due to invasion of the brachial plexus or adjacent structures. It is typically associated with other symptoms like arm weakness or weight loss.
- Osteoid osteoma: A benign bone tumor that can cause nocturnal pain relieved by NSAIDs. While possible, the location and nature of the pain, along with the absence of night pain, make this less likely.
- Referred pain from abdominal pathology: Certain abdominal issues, like pancreatitis or a splenic rupture, can refer pain to the back. However, these conditions usually present with other significant symptoms like abdominal pain, fever, or systemic illness.